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Great job! Next step: let's complete your enrollment.

By filling out the online enrollment form, you're officially requesting to enroll with Insurance Company. After we submit your enrollment to CMS, you'll be notified whether it's been accepted or denied.

Medicare Star Rating
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Company Name Medicare Choice (PPO) - H0885 001

2024
$545

In-Network Deductible

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$700

Preffered Retail Cost ShareCo-pay for Preffered Tier 1 Generic Drud

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5 of 8

Drugs Covered

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Pharmacy Coverage
NY Medical
Drug Coverage
methadone HCl
$24.40

Monthly Premium

0$

Preferred Costs

Great job! Next step: let's complete your enrollment.

By filling out the online enrollment form, you're officially requesting to enroll with Insurance Company. After we submit your enrollment to CMS, you'll be notified whether it's been accepted or denied.

My Personal Information

First Name *
Last Name *
Gender

My Address

Permanent Residence street address (Do not enter a PO Box)

Address *
Apt/Ste
City
State
county
zip code
Address
Apt/Ste
City
State
county
zip code
Mailing address is different from permanent residential address

* Required Fields

Congratulations! Now, let's get you enrolled.

By completing the online enrollment application, you will be sending an actual enrollment request to UnitedHealthcare ® Insurance Company. You will receive a notice of acceptance or denial following submission of the enrollment to CMS.

My Medicare information

Please enter the details below exactly as they appear on your Medicare card.

Medicare Number *
Re-Type Medicare Number *
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Your Medicare infromation is secure and will be transmitted safely to your plan provider.

Please select the statement that best describes your current state
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Requested Coverage Effective Date

My Primary Doctor

It's highly advised to provide your primary care physician's (PCP) information. If you're applying for an HMO plan or a plan requiring a PCP, this section must be completed. Otherwise, your insurance plan will assign one for you.

Primary Care Physician Name
PCP ID Number
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Do you currently see the physician you've chosen? (Optional)

My Current Coverage
After enrollment, will you have additional medical health coverage, either as the primary subscriber or as a spouse/dependent? (optional)
Besides Insurance No Premium H868-019 (HMO), will you also have any additional prescription drug coverage, such as VA or TRICARE?

Preferred Method for Monthly Payments

No payment is required today!

Please select your method of premium payment:

If no payment method is chosen, you will receive a coupon book or direct bill. Once your enrollment in a plan is confirmed, you can choose to pay by credit card.

Automatic withholding from my Social Security benefit check.

* Required Fields

Congratulations! Let's move forward with your enrollment.

Please carefully check your enrollment details before proceeding, as they cannot be modified later.

Review My Application

  • Applicant Name
    John Doe
  • Your Enrollment Information
    Review Enrollment formYou can review the application before submitting
  • Enrollment Plan
    Company Name Medicare Choice (PPO) - H0885 001
  • Effective date
    01/01/25
  • Monthly Plan Premium
    $12
  • Star Rating
    4,2 out of 5 stars
  • Monthly Plan Premium
    Summary of benefits

My Plan’s Important Information

Please ensure you read the disclosures thoroughly until the end and tick the box to verify that you have read them.
To finalize your enrollment, click the "Submit Application" button.

Disclosures

  • To remain enrolled in Company Name H0913-021 (HMO), I need to maintain coverage under both Hospital (Part A) and Medical (Part B insurance. By enrolling in this Medicare Advantage Plan, I consent to Company Name H0913-021 (HMO) disclosing my information to Medicare for purposes such as monitoring my enrollment, processing payments, and other legally permitted activities, as detailed in the PRIVACY ACT STATEMENT.

The Centers for Medicare & Medicaid Services (CMS) gathers data from Medicare plans to oversee beneficiary registrations in Medicare Advantage.

My Personal Information

Phone number
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Email
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Who Is Enrolling?

My Signature?

Full Name *
Re-type Full Name *

Upon submitting your application, a confirmation number will be issued to you. Should there be any incomplete or unverifiable information, further details may be requested.

Please check this box to complete enrollment

* Required Fields

Review my Application

Review and if you need to make changes, tap the Edit link next to the section header.

My Important Information

First Name

John

Last Name

Doe

Birth Date

10/10/1949

What is Your Preferred Language

Spanish

Alternative format

My Contact Information

Address

NeyCastella st, 17

City

Shelton

Zip Code

06484

Countу

Fairfield

Email
[email protected]

My Medicare Information

Medicare
Medicare number

1EG4-TE7-MK73

Start date of Part A (Hospitalization)

01/12/2024

Part B (Medical Services) Start Date

01/12/2024

My Primary Doctor
Who is your primary care doctor?
What is your PCP ID number?
29383838
Are you a patient of the doctor you chose?
My Current Coverage
Once enrolled, will you have other health insurance where you are the owner or are you covered as a spouse/dependent?
Will you have other prescription drug coverage in addition to the plan you are enrolling in?

Save Your Progress

To save your choices on the Medicare Pal self-enrollment form, please enter your email address below. We will send you a link that allows you to resume your session whenever you wish.

Submit